Mental Health Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Prefer not to say
Address
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone
Insurance Information
Insurance Provider
Policy Number
Clinical Information
Reason for Visit / Primary Concerns
Mental Health History
Current Medications
Allergies
Other Providers (if any)
Consent & Signature
I consent to treatment and the use of my information for my care.
Signature
Date